Visiting Nurse Association of Boston

“Patient’s or legal representative’s signature CFR(s): 484.50(a)(2) Obtain the patient’s or legal representative’s signature confirming that he or she has received a copy of the notice of rights and responsibilities. This Element is not met as evidenced by: Based on record review and interview, the agency failed to obtain the patient’s signature to confirm he/she had received a copy of the Patient Handbook and Patient Education Workbook including patient rights and responsibilities for 2 patients (#1 and #6), out of a total sample of 17 patients. Findings include: B. Patient #6 was admitted to the agency in April 2025 with a diagnosis of hyperlipidemia and was discharged to the agency June 2025. Review of the physician’s’ orders for certification period 4/30/25-6/28/25 indicated the following: *Skilled Nursing visits (SNVs): 2 times a week for 1 week, then 3 times a week for 1 week, then 2 times a week for 6 weeks, and then 1 time a week for 1 week. *Physical Therapy (PT): 1 time a week for 1 week. *Occupational Therapy (OT): 1 time a week for 3 weeks Review of the Patient Consent, dated 4/30/25, indicated that no electronic signature was obtained due to infection control, verbal consent obtained. Review of the medical record indicated that the client provided an electronic signature for the services provided in accordance with the plan of care during the certification period. During an interview on 8/21/25 at 1:40 P.M., the Administrator said that the patient should have signed the consent and there was no documentation in the medical record to support a rationale for why the patient did not. Review of the agency policy, titled, Informed Consent/Refusal of Treatment, updated May 2024, included the following: Purpose: To obtain written consent for care during the admission process and to communicate the organization’s process for informing patients and family/caregivers regarding services as well as involving patients in the care/service planning process. Policy: Upon admission and throughout the course of care/service, the patient and family/caregiver will be: Given information, in an understandable language, to make informed decisions regarding the care/services being provided.Encouraged to participate in the care/service planning process, including planning for transfer, referral, and discharge.Allowed to refuse all or part of his/her care/service to the extent permitted by law; the expected consequences of such actions must be explained.During the admission visit, the patient or authorized representative will sign the organization’s written consent for care/service.A. Patient #1 was admitted to the agency in June 2025 with a diagnosis of hyperlipidemia and required home health services. Review of the physician’s’ orders for certification period 6/28/25-8/26/25 indicated the following: *Skilled Nursing visits (SNVs): 1 time a week for 4 weeks, then 1 time every other 2 weeks for 4 weeks, and then 1 time a week for 1 week. *Physical Therapy (PT): 2 times a week for 2 weeks, and then 1 time a week for 1 week. *Occupational Therapy (OT): 1 time a week for 1 week, then 2 times a week for 3 weeks, and then 1 time a week for 1 week. Review of the Patient Consent, dated 6/28/25, indicated that no electronic signature was obtained as client cannot read or write, verbal consent obtained. Review of the medical record indicated that the client provided an electronic signature for the services provided in accordance with the plan of care during the certification period.”

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on record review and interview, the agency failed to ensure that a review of medications included allergies to identify potential adverse reactions or side effects for 1 patient (#12), out of a total sample of 17 patients. Findings include: Patient #12 was admitted to the agency in July of 2025 with a diagnosis which included age related osteoporosis with pathologic fracture and chronic obstructive pulmonary disease and required home health care services. Review of the clinical referral, dated 7/29/25, indicated the following allergies: Gabapentin and levofloxacin (antibiotic). Review of the Home Health Care Certification and Plan of Care, dated 7/30/25 to 9/27/25, indicated no known allergies. During an interview on 8/21/25 at 9:15 A.M., Clinic Manager #1 said that the allergies listed on the referral should have been added into the plan of care.”